experiences from hiv sensitive social protection

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Experiences from HIV-sensitive social protection Brian Lutz Policy Specialist, HIV Practice, UNDP Symposium on social determinants of TB 15 February 2012 London School of Hygiene & Tropical Medicine

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Page 1: Experiences from HIV Sensitive Social Protection

Experiences from HIV-sensitive social protection

Brian LutzPolicy Specialist, HIV Practice, UNDP

Symposium on social determinants of TB15 February 2012y

London School of Hygiene & Tropical Medicine

Page 2: Experiences from HIV Sensitive Social Protection

Context and objectives

• TB has well-known social determinants – these may have a more profound impact than does direct medical care (e.g., DOTS)

• Social protection, which is receiving increasing attention globally, is potentially one option to address social determinants

• But little is known about the effectiveness and feasibility of social protection approaches to TB

• HIV has (relatively) more experience in using social protection approaches Though still evolving these experiences could informapproaches. Though still evolving, these experiences could inform if and how social protection can influence TB outcomes – and / or what direction future research might take.

• This presentation summarizes concepts and examples in social protection approaches to HIV

Page 3: Experiences from HIV Sensitive Social Protection

Social determinants matter for TB and other diseases

Historical declines in major infectious disease mortality in the United States

Page 4: Experiences from HIV Sensitive Social Protection

Social protection is a global opportunity

The Social P t ti Fl Protection Floor Initiative:

1 of the 9 initiatives 1 of the 9 initiatives to confront the global economic crisis and economic crisis and accelerate recovery

Page 5: Experiences from HIV Sensitive Social Protection

Conditional cash transfers, for example, have spread

•29 developing countries had CCTs by 2008 – most conditional on MCH or education• Brazil’s Federal program, Bolsa Familia, now reaches 11 million families, or 46 million people

M i ’ O t id d 5 illi h h ld• Mexico’s Oportunidades now serves 5 million householdsSource: World Bank 2009 “Conditional Cash Transfers”

Page 6: Experiences from HIV Sensitive Social Protection

But questions linger on social protection for TB

What social protection Where and how protection approaches might work?

should they be targeted?

Are they f ibl ? Wh t i

Can social protection

feasible? What is required to implement andprotection

influence TB outcomes?

implement and scale-up?

Page 7: Experiences from HIV Sensitive Social Protection

HIV offers three key messages

1. Social protection has many potential entry points to influence health outcomes

2. But social protection is not a magic bullet;2. But social protection is not a magic bullet; challenges, risks and unknowns remain

3. For social protection to work, especially for prevention multisectoral frameworks are requiredprevention, multisectoral frameworks are required

Page 8: Experiences from HIV Sensitive Social Protection

Social protection exists across a spectrum

Type of SP Examplespa

city

Transformative Equal rights/social justice legislation, affirmative action policies, asset protection

onal

cap Promotive Agriculture inputs, asset transfers,

microfinance

sfor

mat

io

Preventative Insurance (health, social, disaster, unemployment)

ng tr

ans

Protective Social assistance/transfers: cash transfers, food aid, fee waivers, subsidies

ncre

asin

Social services, which normally target those experiencing illness, disability, violence conflict etcI violence, conflict, etc.

Page 9: Experiences from HIV Sensitive Social Protection

Entry points exist across the HIV continuum

Impact mitigation

TB could differentiate between prevention of infection and prevention of active disease

Page 10: Experiences from HIV Sensitive Social Protection

Cash transfers have multiple entry points for HIV prevention

Prevention Treatment Impact mitigationentry points for HIV prevention

OutcomesProximal servicesDistal / structural risk factors*

HIV risk5

Poverty / Inequality

1

Biomedical and behavioral services2

4q y

servicesGender

2

3

Proxies for HIV risk

Education3

6

Links between cash transfers and HIV risk

1 Impacts of UCTs/CCTs

2 Target and gendered impacts

3 Conditionality for CCT

4 Conditionality for CCT

5 Conditionality for CCT

6 Conditionality for CCT3 Conditionality for CCT 6 Conditionality for CCT

Page 11: Experiences from HIV Sensitive Social Protection

Cash transfers have reduced poverty and inequality, but downstream HIV impacts are not typically tracked

1

• Very strong evidence

Impact of cash transfers Specific measures

• Modest decreases in poverty• Very strong evidence for sizeable reductions in national poverty

• Modest decreases in poverty headcount

• Strong decreases in severity of poverty (poverty gap andnational poverty poverty (poverty gap and squared poverty gap)

• Red deRed de ProteccionSocial -Nicaragua

• Some evidence for reductions in

• Declines in Gini coefficient

Nicaragua

national inequality

HIV impacts would have to be inferred: Sources: Fiszbein 2009; Soares HIV impacts would have to be inferred: little to no linking of pathway from CCT

income HIV risk or proxies

;et al. 2009; Paes de Barros 2006

Page 12: Experiences from HIV Sensitive Social Protection

The targeting and impacts of cash transfers tend to be gendered

2

• Mothers are often the target recipients of CCTs, especially those dealing with MCH services and education

• Women and girls are disproportionately at risk for HIV, especially at younger ages and due partly to economic inequalities along gender lines

• Women and their social networks have positive spill-over effects in CCTs for VCT:• Women (but not men) had small uptick in VCT access when neighbors

received CCT • When women received CCT, their husbands were more likely to attendWhen women received CCT, their husbands were more likely to attend

(but not vice versa)

• Some studies have shown that the income effects (separate from the• Some studies have shown that the income effects (separate from the conditionality) of a CCT for HIV status tend to have opposite effects on men and women. Men increase risky sex while women decrease risky sex.

Sources: Thornton 2005 and 2008; Kohler and Thornton 2010 working paperSources: Thornton 2005 and 2008; Kohler and Thornton 2010 – working paper

Page 13: Experiences from HIV Sensitive Social Protection

Cash transfers have been shown to address structural drivers effectively and reduce HIV risk (Zomba study)

1

2

3

%6

0 %

Case study: CCT in Zomba, MalawiAdolescent girls randomized to receive cash transfer (avg = USD• Adolescent girls randomized to receive cash transfer (avg = USD 10/month to girl and family), some conditional on school attendance

• Results:• 60% decrease in HIV risk (1 2% vs 3 0%) and 75% decrease in HSV 2• 60% decrease in HIV risk (1.2% vs. 3.0%) and 75% decrease in HSV 2• 3-4 times more likely to be in school• More likely to delay marriage and pregnancy• Less sex including transactional sex and younger partner selection• Less sex, including transactional sex, and younger partner selection

Source: Baird et al. 2010. in Health Economics; World Bank Brief 2010

Page 14: Experiences from HIV Sensitive Social Protection

Zomba study cont: The income effect is a clear part of the pathway; schooling effect is less clear

1

2

3

Income or Schooling? (using the unconditional treatement group only)                     Prevalence of "any STI" by treatment status and school attendance in 2008.

Did not attend school l l i 2008

Attended school l l i 2008

Total

e a e ce o a y S by t eat e t status a d sc oo atte da ce 008

Control 14.7% 2.8% 5.2%regularly in 2008 regularly in 2008

Unconditional treatment 0.0% 2.0% 1.7%Total 11 6% 2 6% 4 3%

Source: unpublished World Bank brief 2010; presentation at Vienna AIDS conference 2010. Peer-reviewed publications forthcoming

Total 11.6% 2.6% 4.3%

reviewed publications forthcoming

Page 15: Experiences from HIV Sensitive Social Protection

Cash transfers have multiple entry points for HIV prevention

Prevention Treatment Impact mitigationentry points for HIV prevention

OutcomesProximal servicesDistal / structural risk factors*

HIV risk5

Poverty / Inequality

1

Biomedical and behavioral services2

4q y

servicesGender

2

3

Proxies for HIV risk

Education3

6

Links between cash transfers and HIV risk

1 Impacts of UCTs/CCTs

2 Target and gendered impacts

3 Conditionality for CCT

4 Conditionality for CCT

5 Conditionality for CCT

6 Conditionality for CCT3 Conditionality for CCT 6 Conditionality for CCT

Page 16: Experiences from HIV Sensitive Social Protection

CCTs have been shown to increase uptake of VCT4

Case study – CCT for VCT in Malawi

Methodology: Community-randomized control trial

Design: • cash transfer = USD 0-3 (mean 1.04)

diti lit t i i VCT lt• conditionality = retrieving VCT results

Results: • CCT-recipients 2x likely to get VCT results

vs controls (increase of 27-39%)• Each USD 1 of transfer = increase 9%Each USD 1 of transfer increase 9%• Final attendance = 72%

Source: Thornton 2005 and 2008;

Page 17: Experiences from HIV Sensitive Social Protection

So far, CCTs tied directly to HIV status have not shown effect

5

Case study – CCT for HIV status in Malawi

M th d l RCTMethodology: RCT

Design: • cash transfer = USD 0 4 or 16cash transfer USD 0, 4 or 16• conditionality = remaining HIV negative• 1 year time lapse before incentive

I l d PLHIV• Include PLHIV

Results: • No effect on HIV status or reported sexualNo effect on HIV status or reported sexual

behaviors• After final incentive paid, men increased risky

sex while women decreased risky sexsex while women decreased risky sexIssues: stigma, frequency of incentive, perverse incentives, income effect vs conditionality

Source: Kohler and Thornton 2010 – working paper

Page 18: Experiences from HIV Sensitive Social Protection

CCTs tied to curable STIs, however, have been shown to reduce biomarker proxies for HIV risk

6

Case study – CCT to remain STI-free - Tanzania

M th d l RCTMethodology: RCT

Design: • cash transfer = USD 0 10 or 20 (every 4 months)cash transfer USD 0, 10 or 20 (every 4 months)• conditionality = remaining free of ~ 6 curable STIs• HIV status not considered, not measured; PLHIV includedincluded

Results: • USD 10 / 4 months = no effect• USD 20 / 4 months = 25% reduction in STIsConclusions: • CCTs tied to HIV proxies can work• CCTs tied to HIV proxies can work• Value of cash transfer matters• Curable STIs can be non-stigmatizing proxy

Source: RESPECT study World Bank 2010

Page 19: Experiences from HIV Sensitive Social Protection

Social protection can facilitate HIV treatment access directly and indirectly

Prevention Treatment Impact mitigation

HIV treatment access directly and indirectlySome examples

• Cash transfers or vouchers for transportation

• Food/nutrition assistance

Uganda – RCT showed $5-8 per month improved adherence and retention

Direc

t • Food/nutrition assistance• Reduction in stigma and discrimination in

medical service deliveryAb liti f f

adherence and retention

• Abolition of user fees• Health insurance reforms

India – New insurance guidelines to cover PLHIV

irec

t • Social protection that creates or frees up resources, such as time and money, for treatment adherence (e.g., life and disability insurance, nutritional support abolition/payment of school fees)

Ind nutritional support, abolition/payment of school fees).

• Includes mitigating impacts related or unrelated to AIDS

Source: Economic Times 4 February 2012; Emanyanu et al. 2010

Page 20: Experiences from HIV Sensitive Social Protection

UNDP-sponsored studies demonstrate impact of AIDS at household levelat household level

Prevention Treatment ImpactMitigation

M th d l i l iMethodological overview• 5 countries co-led: Cambodia, China, India, Indonesia and Viet Nam• Surveys conducted 2004-2010

S f k lt

• Matched case-control methodology: 7,000 affected HHs, 10,000 non-affected control HHs

Summary of key results• Negative economic impacts (income, poverty, employment and asset

ownership)• Negative impacts on coping mechanisms (savings, debt, asset liquidation)• Negative impacts on food security• Increase in health spending, at expense of educationIncrease in health spending, at expense of education• Negative impacts on education (attendance, drop-out rates)• Negative impacts in some countries on health-seeking behavior

Hi h l l f ti d di i i ti• High-levels of stigma and discrimination

Page 21: Experiences from HIV Sensitive Social Protection

Social protection can play a role in mitigating the multiple impacts of AIDS Prevention Treatment Impact

mitigation

Social protection interventions*

Poverty

Impacts of AIDS*

cash and asset transfers insurance (social

mitigation

• Poverty

• Unemployment

• cash and asset transfers, insurance (social, health), microfinance

• law and policy reforms, public works

• Hunger and food security

• cash, food and asset transfers, input subsidies, microfinance

• School absenteeism • fee waivers, cash transfers, social services

• Gender inequalities• social transfers and services, transformative

• Stigma and discrimination

social protection (e.g., law and policy reform)

* not exhaustive

Page 22: Experiences from HIV Sensitive Social Protection

Pension reforms in Orissa have helped women widowed by HIV

Prevention Treatment ImpactMitigation

Scheme: Madhu Babu Pension Yojana

• Initiation: Feb 2008

p y

• Initiation: Feb 2008• Entitlement: Lifelong monthly pension• Beneficiaries: Elderly, disabled, widows. Includes

widows of PLHIV or any PLHIV irrespective of agewidows of PLHIV or any PLHIV, irrespective of age.• Implementation agency: OSACS with the district

machinery• PLHIV benefited: 23,052,

Special features:• All PLHIVs irrespective of age, marital status, sex,economic status were eligible to apply for the scheme.• The pension card served as an identity, ensured linkageswith a bank, self help group and the community.• One of the NGOs in Orissa facilitated the process ofOne of the NGOs in Orissa facilitated the process ofavailing the scheme to PLHIVs through their link to workersthereby maximising the scope of this project.

Oth t t i I di h i l t d id d i l ti i il i• Other states in India have implemented or are considered implementing similar pension reforms for people affected by HIV. • Multiple SP exists in India, with opportunities to expand to include people affected by HIV

Page 23: Experiences from HIV Sensitive Social Protection

Life and disability insurance is now available to PLHIV with South Africa

I tPrevention Treatment ImpactMitigation

Key innovation: continuous underwriting

Other impact: access to credit

Page 24: Experiences from HIV Sensitive Social Protection

HIV offers three key messages

1. Social protection has many potential entry points to influence health outcomes

2. But social protection is not a magic bullet;2. But social protection is not a magic bullet; challenges, risks and unknowns remain

3. For social protection to work, especially for prevention multisectoral frameworks are requiredprevention, multisectoral frameworks are required

Page 25: Experiences from HIV Sensitive Social Protection

Snapshot: issues, concerns for social protection for HIV (especially cash transfers)HIV (especially cash transfers)

• Program design• Targeting: recipients, eligibility• Payments: size, timing, frequency• Conditionality selection

RAL

• Conditionality selection• Perverse incentives• Complement vs substitutes

GEN

ER

p• Costs – going to scale, M&E• Cost-effectiveness• Long-term dependency

• Human rights concerns

HIV • Stigma

• Coercion (irreversibility, external barriers)• HIV sensitive vs HIV exclusive• HIV-sensitive vs. HIV-exclusive

Page 26: Experiences from HIV Sensitive Social Protection

Countries balance two basic models of social protection for HIV: HIV-specific and HIV-sensitiveprotection for HIV: HIV specific and HIV sensitive

HIV-specific(stand-alone/vertical)

HIV-sensitive(integrated)

C t i t i ll h b th ki d ith th f ll i i t th fCountries typically have both kinds, with the following issues at the fore:

• Stigma• Cost and feasibility

• Social protection policy and programmatic breadth and coherence y

• Reach

Red = affected by AIDS

• (Unique) needs of different groups, including those affected by HIV

Red affected by AIDSBlack = not affectedby AIDs

Page 27: Experiences from HIV Sensitive Social Protection

HIV offers three key messages

1. Social protection has many potential entry points to influence health outcomes

2. But social protection is not a magic bullet;2. But social protection is not a magic bullet; challenges, risks and unknowns remain

3. For social protection to work, especially for prevention multisectoral frameworks are requiredprevention, multisectoral frameworks are required

Page 28: Experiences from HIV Sensitive Social Protection

Multisectoral frameworks are required

Specific recommendations:

1 Integrate STI/HIV and other health outcomes into ongoing and new1. Integrate STI/HIV and other health outcomes into ongoing and new research of general social protection interventions

2. Consider the multiplicity of impacts in design of HIV-specific social protection interventions, especially in terms of cost-effectiveness and financingand financing

3. Develop cross-sector/ministerial structures for programme design, implementation and monitoring

Variants of these recommendations likely apply to TB as well – for discussion

Page 29: Experiences from HIV Sensitive Social Protection

‘Lessons’ from HIV

1. Design studies rigorously – multiple arms, incentive tiers, tracking biomarkers where possiblebiomarkers where possible

2. Look for ‘structural’ or ‘combination prevention’ approaches (structural bigger than social protection per se)

3 Incorporate feasibility and operational assessments e g costs3. Incorporate feasibility and operational assessments – e.g., costs, cost-effectiveness, implementation models

4. Piggy back on existing research

5 W k ith th h lth d d l t t5. Work with other health and development partners –SOCIAL determinants of HEALTH

Page 30: Experiences from HIV Sensitive Social Protection

Thank YouThank You